各科英文病历集锦耳鼻喉病历

Complete Medical History Medical Number:741514 Name: Ren Jianrong Age: 29 years old Sex: Female Race: Han Occupation: Jobless Nationality: China Marital status: Single Address: Jiangxia county in Wuhan, Hubei. TEL:13545097093 Date of admission: Sept 17st, 2002 Date of record: 5pm, Sept 17st, 2002 Complainer of history: the patient herself Reliability: Reliable Chief complaint: Uncomfortable feeling and excretion in nose for 9 years. Present illness: The patient has felt uncomfortable feeling and had some excretion in nose without obvious causes 9 years ago. The excretion was clear. She did not get fever ,dizziness, vertigo and headache. She went to local hospital, the diagnosis was “Deviation of nasal septum”. The doctor advised her to operation, however, she did not have enough money then .She received some medical therapy (not detailed). Asking for operation, she came to the out-patient department of our hospital this time, and was admitted with the diagnosis of “ Deviation of nasal septum ”. During the course of the illness, her appetite is good, and both her spirit and physical strength are normal. Defecation and urination are normal. Past history She doesn’t have allergic history to penicillin or sulfamide.Denied hypertension, diabetes ect. Diseases. Personal history: She was born in Wuhan on Nov 1st, 1973 and always lived at there. Her living conditions is average. She doesn’t have bad habits . Menstrual history: The first time when she was 14. Lasting 4 to 5 days every times and the cycle is about 30 days.The latest time was on Sept 1st. Obstetrical history: Pregnacy 5 times, artificial abortion five times. Contraceptive history: Not clear. Family history: Her parents are both alive and healthy. Physical examination T 36.4℃, P 80/min, R 18/min, BP 110/76mmHg. She is well developed and moderately nourished. Active position. The skin is not stained yellow. No cyanosis. No pigmentation. No skin eruption. Spider angioma is not seen. No pitting edema. Superficial lymph nodes are not enlarged. Head Ear. Nose .Mouth: See professional examination Eye: No ptosis. No entropion. Conjunctiva is not congestive. Movement is normal. Bilateral pupils are round and equal in size. Direct and indirect pupillary reactions to light are existent. Neck: No masses. Thyroid is not enlarged. Trachea is in midline. Chest Breast: Symmetric bilaterally. Neither nipples nor skin are retracted. Elasticity is fine. Lungs: Respiratory movement is bilaterally symmetric with the frequency of 18/min. Thoracic expansion and tactile fremitus are symmetric bilaterally. No pleural friction fremitus. Resonance is heard during percussion. No abnormal breath sound is heard. No wheezes. No rales. Heart: No bulge and no abnormal impulse or thrills in precordial area. The point of maximum impulse is in 5th left intercostal space 0.5cm inside of the mid clavicular line and not diffuse. No pericardial friction sound. Border of the heart is normal. HR 80/min. Cardiac rhythm is regular. No pathological murmurs. Abdomen: Flat and soft. No bulge or depression. No abdominal wall varicosis. Gastralintestinal type or peristalses are not seen. There is not tenderness and rebound tenderness on abdomen or renal region. Liver is not reached. Spleen is not enlarged. No masses. Fluidthrill negative. Shifting dullness negative. No vascular murmurs. Extremities: Free movements of all limbs. Neural system: Physiological reflexes are existent without any pathological ones. Genitourinary system: Not examed. Rectum: Not examed Investigation Absent. Professional Examination Ear: Bilateral auricles are symmetric and of no masses. No discharges are found in external auditory canals. No tenderness in mastoid area. Auditory acuity is normal. Nose: Normal appearance. There is some clear discharges in nasal cavity. Septum nasi deviates to right. A ridge prominent to right could be seen. No nares flaring. No tenderness in nasal sinuses. Pharynx and larynx:: Oral mucous membrane is smooth, and of no ulcer or erosion. Tongue is in midline. Pharynx is congestive. Tonsils are enlarged(I). History summary 1. Ren Jianrong , female, 29 years old. 2. Uncomfortable feeling and excretion in nose for 9 years. 3. No special past history. 4. Physical examination: T 36.4℃, P 80/min, R 18/min, BP 110/76 mmHg. Superficial lymph nodes were not found enlarged. The lung was normal. HR 80bpm with regular rhythm. No cardiac murmurs. The abdoment were plain and soft. No tenderness or rebound tenderness. Liver and spleen was untouched. No masses. Shifting dullness negative. 5. Investigation information: Absent. 6. Professional Examination: See above. Impression : 1. Deviation of nasal septum 2. Swollen tonsil (I) Signature: Huang Yao 黄 尧 97-10018 PAGE 1